Healthcare Provider Details

I. General information

NPI: 1285262444
Provider Name (Legal Business Name): SIRARE HEZRON BABERE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2020
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 CARVER RD
GRIFFIN GA
30224-3937
US

IV. Provider business mailing address

571 MARIPOSA LN
MCDONOUGH GA
30253-3031
US

V. Phone/Fax

Practice location:
  • Phone: 770-227-9222
  • Fax:
Mailing address:
  • Phone: 404-916-1326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN209504
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: